Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
When do you prefer to use bolus for treating superficial tumors adjacent to or involving the skin surface, especially for complex surface anatomy in the pelvis, head/neck, and extremity regions?
There is not a single answer to this question, as it depends on the specifics of the geometry, treatment technique (photons vs. electrons, beam angles, energy used, etc.), depth and size of the tumor, and other technical factors. Since almost no one has access to superficial or orthovoltage X-rays w...
How long would you continue second line maintenance PARP inhibitor in a patient with recurrent stage IV BRCA+ ovarian cancer who had CR and remains NED?
For patients with platinum-sensitive relapsed ovarian cancer with a partial or complete response to platinum-based chemotherapy, niraparib, olaparib, and rucaparib are approved by the FDA for maintenance therapy. While PFS outcomes are improved with these agents regardless of BRCA mutation status, t...
What is your dose-fractionation for cylinder-based vaginal cuff HDR brachytherapy for an isolated vaginal cuff recurrence after whole pelvis EBRT with residual thickness of disease <5 mm?
I usually prescribe 5Gy x5. I don't prescribe to a fixed thickness but treat based on residual thickness seen on MRI using multichannel applicator.I lesion at apex then treat upper 2-3 cm of vagina Here is out paper describing technique and outcome in detailhttps://www.ncbi.nlm.nih.gov/pubmed/299299...
Extrapolating from KEYNOTE-A18, would you consider adding pembrolizumab to chemoradiation for locally advanced vulvar cancer?
This is a very interesting and important question. Although we have no prospective data on vulvar cancer regarding this question, our treatments have invariably paralleled the cervix. PD-L1 expression is estimated to be ~50%. Similarly, in KEYNOTE-158, RR in PD-L1 + cervix cohort was 15%, while in t...
How would you counsel a young female patient who refuses to use contraception during radiotherapy?
A woman who refuses contraception needs careful psychological and psychiatric assessment and considerable time at the time of consultation to understand why she is refusing, especially since this response is neither rational nor logical. The practitioner needs to take the time to discuss the patient...
How do you approach radiation treatment of extramammary Paget's disease of vulva, diffusely involving the urothelium and the periurethral glands?
Very unusual case. Presuming it has invasive disease, would also check HER2/neu status to see if there is any value of indication with chemo and anti-HER2/neu therapy. Will plan definitive chemo RT treating vulva, vagina, urethra, and bladder (if involved) to 66-70 Gy to gross disease and prophylact...
In vulvar cancer patients with a well lateralized primary s/p vulvectomy and ipsilateral LND meeting nodal-based criteria for adjuvant RT, would you consider RT to the ipsilateral groin and pelvis?
Risk of contra lateral node involvement for lateralized lesion is a function of the size of tumor, thickness of tumor and number of positive nodes in the ipsilateral groin (>2 node). If the contralateral node has not been assessed by dissection or SNLB then I would treat both groins all the time. If...
When would you continue bevacizumab versus using PARPi alone for maintenance therapy in BRCA+ or HRD+ ovarian cancer after response to primary platinum + bevacizumab?
In patients who start treatment with combination platinum based chemotherapy + bevacizumab, and are found to be BRCA+ or HRD+, I will commonly continue bevacizumab and layer on the PARPi in the maintenance setting. This is based on both the PAOLA-1 data, as well as the population adjusted indirect c...
How do you counsel patients with locally advanced malignancies who have ECOG 3-4?
I agree with @Dr. First Last and @Dr. First Last's comments about the implications of PS and specific situations where medical therapies have the potential to improve PS (heme malignancies small cell) and/or extend quality of life. I have two goals in this conversation. To make sure I understand the...
What is your strategy for breakthrough chemotherapy induced N&V in patients receiving highly emetogenic chemotherapy and already received a NK-1 antagonist, 5-HT3 antagonist, dexamethasone, and olanzapine?
I find the MASCC anti-emetic guidelines to be very well written Davis et al., PMID 34398289.Very few randomized clinical trials in cancer for antiemetics (with positive trials associated with metoclopramide (D2 receptor antagonist) and olanzapine).So - most are based on trial and error + clinician p...